Primary Care Coding Alert

With long summer days right around the corner, fitness fanatics long cooped up inside will grab their cobwebbed bicycles, landing your family physician (FP) with treating cuts and pebbly knees. Before you code another simple repair, make sure you're not missing out on reimbursement by undercoding your FP's services and falling into fraudulent billing.

One of the biggest mistakes that FP coders make is reporting a simple laceration repair rather than an intermediate repair, says Marie Felger, CPC, a family practice coding consultant and American Academy of Professional Coders (AAPC)-certified coding instructor with Joy Newby & Associates LLC in Indianapolis. It's an error that can cost your practice revenue, not to mention the danger you create by not coding to the highest specificity, Felger warns.

"Physicians often do not give enough information for coders to know whether an intermediate repair was performed," Felger says. In this case, the coder will report a simple repair.

To stop incorrectly reporting laceration repair, check the documentation and your skills at selecting the right code.

When choosing between simple (12001-12021) and intermediate (12031-12057) repair codes, encourage your FP to use specific language. You should report a simple repair when the wound is superficial, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa. Wounds that primarily involve the epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, require a simple one-layer closure.

"Intermediate repair includes the repair of wounds that, in addition to the work involved in a simple repair, require closure of one or more of the deeper layers of subcutaneous tissue and superficial fascia," Falbo says. Complex repair requires more than layered closure.

FPs often fail, however, to mention intermediate repair or how many layers they closed, Falbo says. Doctors should use terms such as "deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia," "layered closure" or "deep layer suturing" to indicate they performed an intermediate repair, she says.

For instance, a physician may suture a deep subcutaneous wound, which would require layered closure. If the documentation fails to mention the layered closure, the coder will miss that and report a simple repair code rather than the more accurate and higher-paying intermediate repair code, Felger says.

Another area your FP should include in chart notes is the extent of debridement he or she performs. Although intermediate repair usually requires layered closure, single-layer closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter also constitutes intermediate repair, according to CPT's repair (closure) notes.

But many doctors forget to state that they performed decontamination or debridement of a large area, Felger says. In this case, she says the coder will not know that the repair qualifies for an intermediate repair and will instead use a simple repair code.

For instance, after falling off his bicycle, a male patient presents with a 2.7-cm gash on his right knee and shin. Because the fall occurred on a steep embankment, the road rash contains a lot of gravel, which requires extensive debridement. If the FP writes "sutured 2.7-cm wound R knee/shin" and fails to include "extensive debridement," the coder will report 12002* (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm), which contains 4.24 relative value units (RVUs) and reimburses on the Medicare Physician Fee Schedule at $155.99, instead of the more accurate 12032* (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm]), which has 5.6 RVUs and pays $206.02. This error will sacrifice $50 ($206.02-$155.99 = $50.03) in entitled reimbursement.

Before you blame poor documentation for all laceration coding mistakes, make sure you're properly billing what the chart report contains. Although reporting a single repair may seem simple, billing for multiple lacerations kicks the coding skill up a notch. To maximize entitled reimbursement and ensure ethical coding, check your knowledge of the multiple-laceration formula.

Combining several repairs is based on the repair class, such as simple or intermediate, and the anatomic site. When coding for several repairs, first tally the number of wounds in the same classification. If the wounds are also in the same anatomic area, add the repairs together for one total, Falbo says.

Pay attention to CPT body groupings, which may change based on the repair's class. For instance, CPT includes hands, feet and/or extremities in the same anatomic site for simple repairs (12001-12007), Falbo says. The intermediate repair codes for extremities (12031-12037), however, exclude hands and feet.

For instance, an FP repairs a 3.2-cm superficial wound on a patient's right hand and a 5.4-cm simple laceration on the patient's arm. Because the wounds are in the same class and anatomic site, you should total the measurements (3.2 cm + 5.4 cm = 8.6 cm) and report one code: 12004* ( 7.6 cm to 12.5 cm). "On the other hand, if the repairs are in different classes or in different groupings of anatomic sites, you should report them individually," Felger stresses.

When you separately bill dissimilar lacerations, reimbursement hinges on using the proper modifier on the right code. To report repair of more than one classification or grouping, list the more complicated laceration repair as the primary procedure and the less complicated as the secondary procedure, according to CPT. And, you should append modifier -51 (Multiple procedures) to the subsequent code, Falbo says. The payer, based on multiple-procedure rules, may reduce payment for the secondary procedure by 50 percent.

This reduction makes appending modifier -51 to the right code crucial. The more complicated procedure will have more RVUs and a higher reimbursement rate than the less complicated procedure, Felger says. Therefore, reversing the order will lessen your practice's revenue.

Consider an 8-year-old boy who falls off his bike onto a sidewalk strewn with glass. The boy has three cuts that require repair: a 2.8-cm superficial wound on his left shoulder, a 1.1-cm simple laceration on his left ear, and a 3.9-cm wound on his knee that requires layered closure.

To code the scenario, follow the earlier classification and grouping recommendations. First look at the two repairs that require simple closure. Although the shoulder and ear wounds are in the same class, they are not in the same anatomic group. Therefore, you should separately report each repair. For the 2.8-cm simple repair on the shoulder, you should assign 12002. For the 1.1-cm superficial ear laceration, you should use 12011* (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less). Finally, 12032 is the correct code for the intermediate knee repair.

After determining the appropriate codes, you need to put them in the right order. Start with the most complicated procedure, which contains the most RVUs: 12032. All subsequent codes will require modifier -51 to indicate they are multiple procedures, Falbo says. The next two codes, 12011 and 12002, contain the same RVUs (4.24). Therefore, you may list 12011-51 or 12002-51 second.